Sometimes I've Believed as Many as Six Impossible Things Before Breakfast

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We are the biggest threat to the ICU; doctors, intensivists, the people that do our job.

Intensive care is the greatest specialty in medicine. Sure, I am biased, but I am allowed to be and really you should be excited about that, you should be grateful. There are of trainees up and down the country who, like me, apply for intensive care because they have a passion, because they want to be great single specialty intensivists. What do we say to these people?

We say ‘and what else will you do?’.

We say ‘when are you going to think about your second specialty?’

Sometimes we say ‘but you’ll never have the skills of an anaesthetist’ and often we say ‘it’s prudent to have a second string to your bow’.

If you’re a trainee and you haven’t heard that last phrase from a supervisor or mentor, I am surprised. But what does it mean? To have a ‘second string to your bow’. It is of course a phrase originating from archery and makes reference to having a second string incase the first one breaks. It is a back-up; the second string was never meant to be used at the same time as the first. A single, strong, resistant thread is what makes a bow effective.

This is not an argument against dual training. It is an argument that dual training is not the answer to burnout and it is not the right answer for everyone. It is an argument that wonders why we nurture so readily the expectation that you won’t ‘just’ CCT in ITU? Yes, we have created stand-alone ICM training, but are we actually encouraging it to stand alone?

Intensive care already has the benefit of drawing its trainees from different streams of core training and special interests will of course always be of value at both an individual and departmental level. There are however a myriad of interests and skills which can be developed and maintained outside of formal dual accreditation.

People will talk about job plans, they say ‘you know the reality is…’ They’re not wrong, job plans matter and remain a stumbling blog for a number of acute specialties. The Royal College of Emergency Medicine report ‘Stretched to the Limit’ found that 62% of current job plans were felt unsustainable by emergency medicine consultants and when asked what would support more sustainable working within their specialty the number one suggestion was to actually change the job plans (1). Job plans are a reality that we created and we are the ones who ultimately have the power to drive the change that is needed.

Instead, we take trainees who want to be full-time intensivists and immediately instill in them a worry that there might not be job security with a single specialty. As one of those trainees, it feels like a ‘computer says no’ attitude and the future of intensive care is surely more important than that?

People will talk about the mental toll, they will say ‘you know the reality is…’ and again they’re not wrong. There is an emotional toll to be paid of course, but when we insist this is absolutely unique to our specialty, we flatter ourselves. There are huge challenges to be met, but we are the ones with the power to make intensive care the most well supported specialty in medicine. Other specialties already do it much better and saying ‘it’s just too much, you have to do something else’ is an indulgence, it is a cop-out and it is not an answer.

In 2002, a survey of all intensive care society members currently working in intensive care found that 29% of respondents had signs of psychiatric morbidity, but the level of mental health problems was not associated with age or long hours of work(2). They did however highlight that many important stressors that were identified could be modified by improved team work and resources. As a trainee, I am repeatedly ‘warned’ that stand-alone training is not sustainable because the hours are too long and ‘nobody wants to be doing that when they get older’. I am repeatedly advised that stand-alone training will lead to burn out and that dual accreditation is the answer. The truth is, there are no large randomized controlled trails that have examined strategies to counteract the phenomenon of burnout in intensive care doctors.

So yes, the future of intensive care is under threat, but its stands with an army of trainees, some of whom want to be single specialists. What sort of leader, recognizing that, would tell its soldiers ‘no, just give me 50% of your commitment, passion and drive’ and how can we expect victory in battle when we are so ready to tell our soldiers to just accept that the end goal, the career, is de facto not sustainable?

Intensive care could, I think, be the greatest stand-alone career in medicine, but until we are willing to support and create that reality; we are the biggest threat to the future of the ICU.

Listen to an audio of this blog and subsequent roundtable discussion – via ICN Podcasts

Whistleblowing is turning into one of those buzz words that just puts people in a bad mood. It is a word which is fast becoming overused and somewhat unfit for purpose. Those of us who work in hospitals realise that the best environment for listening to concerns and learning from error in a dynamic and timely way is one where nobody needs to employ the cacophonous screech of a whistle. Quiet words, routine conversations, an environment where all you need to raise a concern is the sound of your own voice; this is the goal.

Semantics aside, the role of whistleblowing guardian however is an important one. A role which, in the CQCs own words “will be responsible for leading local ambassadors across the country so that staff feel safe to raise concerns and confident that they will be heard” (1). A laudable aim, without doubt.

But does she have a point? Undoubtedly yes. That morale within the NHS is at a frightening ebb is abundantly clear. Trusts are concerned. In fact, the King’s Funds tells us the issue of staff morale constantly features in the top three of all concerns for financial directors, second only to delays in care and A&E waiting targets this quarter (2). In other quarters it has topped the pile.

The idea that ‘being happy’ will make things better isn’t at all far-fetched. Academics like Simone Barsade have long been telling us the importance mood has on team dynamics; some call it ‘the affective revolution’. In short, improving a team’s emotional culture improves performance and those of us in leadership positions have a greater effect on the group mood. Improving morale is the holy grail of retaining staff and of improving care. It is the only way for top down leadership to really empower change from the ground up.

But who’s job is it to say that, and more importantly how should it be said? I would argue not our whistleblowing guardian and certainly not through the type headlines we read last week.

Environments that support staff to speak up are ones in which they feel safe to do so. If you take a group of foundation doctors and ask them why they don’t feel comfortable discussing errors, they will tell you that they are worried about judgement. I know because I’ve asked them. In a survey of foundation trainees in my own trust, the top two barriers with overwhelming majority were ‘I don’t want to have a reputation for thinking I know better’ and ‘I am not perfect, so I don’t feel it is ok for me to point out other colleague’s errors’. This is not unique to my research; shame, embarrassment and fear of judgement are all common hurdles when it comes to developing platforms for learning from errors (3).

Our whistleblowing guardian says we need more ‘trust, joy and love’. She asks “wouldn’t it better if oxytocin was the predominant neurotransmitter in the NHS?”; I hear “wouldn’t it better if everyone just stiffened up their lip and plastered on a smile”. Intended or not, it is the implication and to the doctor or nurse struggling with the strain of working an understaffed rota or with the stress of seeing less than optimal care given to patients, what a worrying, demoralizing, deterring message that is.

Smile, it might never happen…..whistle a happy tune, no one will suspect you’re afraid.

People are confused; they are right to be. In actual fact, I’m confused and if you’re a junior doctor and you think our situation is black and white, well then you are probably not being honest with yourself.

There are some absolute truths:

That junior doctors are qualified medical practitioners. They are not students or apprentices. All doctors are life-long learners, we develop more and more acumen as we progress. Consultants are life-long learners too.

That junior doctors are not a road block to ‘7 day services’. This was true before the #juniorcontract war erupted last year and it is true now.

That the #juniorcontract has been wrongfully and willfully conflated with a pretense to provide ‘7 day services’. This conflation is deeply distressing for junior doctors and it remains the biggest roadblock to resolving this dispute since the beginning. In order not to repeat myself here, I would ask you to read this and you may also be interested in this and this breakdown of previous television interviews given by Mr Jeremy Hunt.

That this dispute is escalating the imposition of a contract which has not been either costed or funded appropriately.

That this dispute is escalating a contract which uses tax payer’s money to fund something that doctors believe is not in the best interests of the NHS. Something which has no evidence base.

That this dispute has become too centered on the absolute inability of Mr Hunt to appeal to and lead a massive part of the NHS workforce in any meaningful way.

That junior doctors are genuinely concerned that the imposition of this contract has become a vanity project for the secretary of state for health.

That the struggle of junior doctors to oppose and mirror the whirring machine of government policy has been a clear demonstration of everything that is wrong with achieving progress in the NHS and at the risk of repating myself, perhaps you would like to read this.

That junior doctors are not politicians.

That junior doctors rightly reject policies which see discrimination of the valuable female workforce as collateral damage (detailed here)

That doctors want a contract which allows them to provide a safe service to patients.

That doctors require appropriate pay for their work. That the pay should appropriately remunerate the effect our work has on our home lives. This dispute is partially about pay, I make no apologies for that.

That junior doctors already provide their services at a good price to the NHS.

But there is also lots to be confused about.

That the BMA negotiated for us what they publically referred to as something which ‘is a good deal for junior doctors and will ensure that they can continue to deliver high-quality care for patients’.

That this deal was not only endorsed by the BMA, but by numerous high profile faces of the junior contract dispute, unequivocally and in public.

That the original mandate for strike action is almost a year old.

That the response to the BMA survey designed to gauge appetite for further strike action was poor to say the least.

That the BMA have failed to discredit talk that the committee’s motion for industrial action was separated by a minimum of votes.

That voices from within the BMA comittee have failed to make their voice the most consistent one in this argument and you can see how it may appear that they are running after, rather than leading the pack.

Mr Hunt’s lines are polluted with spin and mistruths, but they seem to be consistent.

That surely these things have grossly undermined the perceived effectiveness of our union.

That as a junior doctor, I don’t actually know what the BMA see as an ‘ideal contract’. If Mr Hunt gave them the opportunity to write their own contract tomorrow, what would it say? Not in a hypothetical, vague over-arching principles sense, but in a real line for line, these are our terms and conditions sense. This should be done by now surely? Perhaps it is, but why haven’t I seen this and how can I support the next industrial action when I can’t find the answer to this question?

These points could go on for longer. I am opposed to the new contract. I am opposed to imposition and I am opposed to the government backed conflation and spin which has led to the escalation of our dispute to this point. However there are many ‘buts’ and in the wake of plans for 5 day industrial action they are buts that that have been echoed by every single one of my colleagues. Not some of them; all of them. There are more than two sides to this argument. These are perhaps not the voices you hear on social media, but the inconvenient truth is that people are so loathe to further discredit the struggle and the credibility of the BMA, that staying quiet seems like an option. Not because people are frightened of a backlash (or at least I am not), but because we do all still want the same things ultimately.

So where do I stand today? Honestly, I stand with my patients. On the week of the 12th of September I will be the intensive care registrar on night duty, I will be in work.

Am I relieved by this? Yes.

Do I think I would be on strike if I was working normal days? I don’t think so, no.

Can you take my lack of surety as an endorsement of current department of health policy or leadership? ABSOLUTELY NOT

This may be unpopular with the vocal, but you only have to take a cursory glance through my previous writing to know that I am on the same side as the BMA. I am on the side of junior doctors and I am on the side of patients. Striking is an individual decision and again I will not re-iterate previous posts like this one at length. It is up to the individual to decide if it is justifiable in the context of their own job. If I am going to walk away from my particular job providing critical care to patients, well then I need to be as sure as I one can be that this method of withdrawing services for 5 days at minimum notice is a possible means to a better end.

Right now, I am just not sure it is. That’s not how you win at politics you say? Please remember, I am not a politician. I am doctor.

Its been an odd year for trainees in the UK; a year of wake up calls, angst, frustration and challenges. Perhaps we can look back in ten years and say that we did the right thing, for the right reasons and in the end it was worth it, perhaps we will look back and say that we tried, and in the end were left with something imperfect, but reasonable and perhaps it will all just be forgotten.

If you’re a junior doctor, June means ARCP; ‘Annual Review of Competencies and Progression. It’s a bit like the week before New Year for medics, when you stand on the edge of your life and try to account for your existence…decide if you’re doing enough to be what you want to be.

Except somebody else is deciding it.

For ARCP, there are boxes on an ePortfolio and the aim of the game is simply to tick all of them. I once sat in front of an ARCP panel who told me without a hint of irony “this is not about how good a doctor you are or not, I have no way of telling that, obviously”. The aim of the game is to tick the box.

I didn’t always hate ARCP. I think it used to fit me.

When you think about it, this isn’t a surprise. When you’re a child, making friends is easy because you don’t really think to much about the other person. it’s not important what they might be able to offer you in the long term or if they want to bring out the best in you. You just want to play hide and seek and then go home and have your dinner; there isn’t a long term plan and you’re just that person that’s playing hide and seek. ARCP used to fit me because I didn’t know who I was.

This year I can firmly say I have never been in worse shape for ARCP. I have never ticked fewer boxes. It’s not that I don’t care. In fact the past month has mostly been a desperate attempt to pull myself back up the ladder. I have trolled shamelessly for work place based assessments. I have scrabbled about for an audit to do.

Lately it just seems our values are too different to be real friends.

ARCP values reflection, it comes as a template. You write in the boxes.

Anyone who knows me knows that I reflect, probably too much. But I don’t reflect in boxes. I have a small number of consultants whose doors I might knock on and they are consultants who I know will listen and tell me the truth. More importantly, they are consultants who know me. I have medical friends who I can thrash things out with. I have Twitter. I think, I talk, I write, I share and if there is an error involved I present it to my colleagues. I have shared four reflections as columns in the BMA news and online this year. Another by Medical Education. I reflect, but not in boxes.

ARCP also values leadership. It values an insight into management.

As I said, it’s been a difficult year for trainees, but it’s also been a year of opportunities. I have been passionate about something. I have engaged members of the public, I have engaged management, I have engaged politicians. I have written I hope, balanced and thoughtful opinion pieces for national news, for the BMA, open democracy and even (to my surprise) a socialist magazine. I was featured across two pages of the BMA news. I had a blog chosen as lead for the Huffington Post and 6 months after I first let loose on my own blog, I had tipped 70,000 views. I have spoken on both national TV and radio.

I have endured being named by a consultant in an ITV news article as symbol of a “generation of doctors (who)… work less hard for more money” and I remained respectful in my reply.

Next month I will be on the interview panel for the safe working guardian at my trust, not because I am completely sold on the new contract, but because I recognise that if we don’t have a voice in that room, it is hard to blame them for not listening.
When we all gasped in horror at the Government’s plan to remove nursing bursaries. I did my best to raise awareness of their petition. I wrote something that was shared more than ten thousand times.

When earlier this year, the wrath of Twitter was unleashed on our physician associate colleagues I wrote honestly about my experiences with them and respectfully about my fears.

I do my best to stand up and be counted. I believe it is important to be in the arena.

You should know though that on my ePortfolio the box for “leadership and management” in my end of year report just reads “Nil”.

“Leadership and management skills development” – Nil

You will understand now why I have no love for ARCP. Five years ago, I’d have told myself I didn’t fit in but I think it’s probably the other way around. It’s doesn’t fit me and you know what? I don’t regret it…after all, how else could I live with myself?

Last night we watched Newsnight’s vague attempt to create a debate between two junior doctors on the same side. The interview set-up of course could never hide the glaring fact that The Department of Health and NHS England remained nowhere to be seen. In the run up to an unprecedented and desperate decision by junior doctors, their absence only confirmed their disgrace. Junior doctors have made it clear that they feel pushed into industrial action by a government who refuse to get back around the table. The point of course that seems obvious to the majority of people outside of The Department of Health is that forced introduction of working conditions that your frontline staff are at odds with was never an option. Mr Hunt will talk to you about time already spent talking, he will tell you that the people of the England need closure on this topic, for the sake of the NHS. The truth is that what the people who rely on the NHS need is an amicable resolution and that is something quite different. Talking remains the only option; for as long as it takes. There will never be a time when Mr Hunt’s ‘nuclear option’ becomes the sensible thing to do.

The absence of any government accountability on Newsnight last night, left two Junior Doctors in the hot seat; orthopaedic surgical Registrar Roshana Mehdian and registrar in palliative care Chris Kane. What I would like to point out today is that the problem was never that these two professionals have slightly different views on our upcoming industrial action. The problem lies at the feet of a media which seems unused to the concept of professional and honest discussion between peers and suspicious of the honesty required in medicine; where we admit to possible risks and discuss them openly, in the hope of coming to the best solution for our patients.

Participation in industrial action for a doctor is difficult and it requires two separate thought processes. First we ask ourselves do we think that a full strike by junior doctors has become warranted on the bases of our treatment and the proposed working conditions? The answer to that question by doctors in overwhelmingly yes. The BMA have triggered action in response to an overwhelming 98% mandate for it’s members. The second question is one that comes to every doctor multiple times per day, whether it is about if you can refuse emergency care within your department or what time you go to bed at at night; is this fair to my patient?

I am taking a liberty here, but I feel absolutely sure that both Roshana and Chris will have been through this exact same though process. At the end of it, they have come to different conclusions, but what we need to remember is that both these doctors can be right, at the same time. Their decisions are both moral and just, within the context of their specific work. The process of questioning the effect everything has on patients requires an honesty and professionalism that we simply do not see in mainstream politics. The politics of junior contract from a government point of view has thus far been about spinning statistics, repeating lines and mistruths and keeping up an appearance of unwavering self assurance for the public. I have said before, that is simply not our fight song, we were never going to sing like that. As medical professionals, our behaviour will always be different, and I am not sorry for it. We are not a political party trying to drag ourselves the top of the opinion polls by whatever means necessary. We are not afraid of honest discussion and we are not afraid to do this openly.

My personal view on the industrial action is that it is the responsibility of every single doctor not to presume safety will be maintained, but to actively check that their departments can cope. Similarly, despite their avoidance of public scrutiny on Newsnight, it is the responsibility of NHS England to take the move by junior doctors seriously and free up emergency and urgent cover as much as possible by cancelling elective, non urgent work. It is also the responsibility of our employer to speak up on a specific trust basis if they feel their own system will not be able to cope; because junior doctors and our consultant colleagues will listen and do everything they can to ensure safety is maintained. Let’s not of course forget that doctors have been coping with an increasing frequency of rota gaps, less than optimal staffing and over reliance on a carousel of locum doctors for a long time now. This is what we do. This is what we are used to.

Next week I will be on strike because I have assured myself that the consultants within my department are perfectly capable of maintaining a safe service. I believe that the majority of junior doctors will be able to come to the same conclusion but I also believe that we should listen to those who have concerns within the context of their work. Last night, Roshana and Chris refused to give Newsnight the standoff they craved and it was entirely the right thing to do.

Junior doctors remain united; one profession, we stand together and we stand with our patients.

Being a member of parliament is an important job, being a Secretary of State more so. I’ve asked Mr Hunt before if he knew what it was actually like to hold a person’s life in his hands. Perhaps, were he to reply, he might answer yes, that he has spent his career making ‘difficult decisions’ and that of course it is his job to champion a safe and patient centred NHS.

He would be wrong.

The truth is that our Secretary of State for Health has absolutely no real experience of what it means to hold a life in his hands. Sure, he make decisions that have the potential to impact broad swathes of people. Sure, unlike me he has the power that comes with his office. Sure, his job is immensely important, but unlike me he has absolutely no responsibility for individual patients in real time. Contained in that statement is everything that is wrong with the modern NHS.

To the MPs of Westminister, as an individual, I am inconsequential. Indeed, you might say that the row over junior contract has taught us that even as part of a voice that is fifty thousand people strong, I am part of something unimportant to policy making. While I might be invisible to our government however, to the patient on front of me I am often everything.

When I stand on front of a patient and tell them not to worry, that I will give them the care they need, it this promise that is the most important thing in the world to that person, and it comes from me….and from every single member of the healthcare team. Promises from the ground up; that is what actually makes a difference to the individual patient.

Everyday, millions of NHS staff make millions of promises to patients. We promise Mrs Smith that we will get her treatment started and do our best to get her home in time for her grandson’s graduation. We tell Mr Clarke not to worry about his upcoming surgery, that he is in safe hands. We tell Mrs Brown that the lump in her breast isn’t cancer…or we tell her that it is, unfortunately, and that we will be by her side through her journey.

It doesn’t matter whether that is a promise to help a patient die where they wish to die or to push on somebody’s mother’s chest and do everything you can do to drag their soul back into a room. It doesn’t even matter if it is merely a promise to save somebody the ice cream that they like while they’re off the ward for a scan, they are all important. It is through these promises that the NHS delivers care to individual patients, every second of every day of the year and each one of these promises is one that the health secretary or even the Primeminister himself cannot make.

I am in the business of individual patients. Our government is in the business of policy.

And what happens when things go wrong? When you look at a patient or their loved ones and recognise that outcomes were not what you or the patient wanted them to be. Sure, the Department of Health may talk of ”learning lessons”, they might pat themselves on the back for the lessons they learned and solemnly promise to carry this forward into policy making. But of what real value is that? What our modern NHS leadership seems to have forgotten is that without me, their promises are useless. Patient care is experienced from the ground-up and Mr Green probably doesn’t care if it is government policy to listen to patients because he is unlikely to every sit on front of the government. When he comes in to hospital what is important to Mr Green there in that moment is just if I actually listen to him.

I am of course not suggesting that the Department of Health is without consequence, but somewhere along the line, it seems to have been forgotten that they are there to support us in our care for patients.

Nurses, doctors, health care support workers, pathologists, radiologists, physiotherapists, porters……the Department of Health forgets that we are the NHS; we are the good, we are the bad, we are the agents for change.

The NHS will only ever be as good as it’s frontline staff and our Department of Health would do well to remember they are just passing by.

In an ideal world, it would be the corporate heads of services and government ministers who would be flat out trying to prove to us that listening to them is worthwhile; that their ideas are sound and their motives are honourable. It should never be the opposite way around and that is everything that is wrong with our NHS and everything that has pushed junior doctors into this mess.

My maternal grandmother was born in 1923. In 1945 she worked as a laundress in Dublin. This was back breaking work, the sort of toil that makes Friday night on the floor in A&E look like an easy ride. In the Summer of that year she stood with 1,500 laundry workers on a picket line with the Irish Women’s Worker’s Union to demand not one, but two weeks paid holiday from her employer as a basic entitlement. The strike was monumental for more than one reason. Other working class unions identified with the laundry women’s struggle and offered support where they could, the power of the ruling classes, government and even the church hierarchy however rallied around the wealthy business owners and as a result the strike was dragged out over some fourteen weeks. For working class women in the climate of post war Europe, this hardship was not to be sniffed at; but they persevered.

Secondly it was a strike by women, who stood firm in their worth at a time when they did not have the luxury of being able to expect equality and when they won, they won a right which was extended to all Industry workers in Ireland.

In 1948, my grandparents married and over the next 15 years between 1949 and 1964, my grandmother had twelve children. When the youngest of her children was about 9 years old she returned to work as a cleaner in a hospital and continued this work until she was seventy years old.

“when the 2007 female cohort [of specialty trainees] become consultants, female consultants will be 55% [of the workforce]. So feminisation is a fact. There is a tsunami of women coming through” .

Personally, I take a little issue with an increase in female consultants being compared to a natural disaster (!) but 9 years later it is interesting to note that according to NHS employers current data, the proportion of female doctors employed as consultants is actually still just 32%. The interest in a growing cohort of female doctors at this time sparked the BBC headline ‘women docs weakening medicine’….a headline which has been be periodically dragged out since, perhaps most notoriously in recent times by Dominic Lawson in The Times.

My grandmother was a tower of strength. She was a giant and I have told you her story because it is one of the reasons I am lucky enough to have grown up knowing the truth; that feminine is anything but weak. To me, the idea that the association of female workers with weakness has continued to drag at the heals of female doctors, even in the twenty first century, is unbelievable. More than unbelievable though, it is just wrong.

You will understand now why, when I tell you that the idea that being female would ever be seen as a negative attribute when I became a doctor was not what I expected at all. Thoughts like that were just not part of my world. When I was half way through my medical degree however I was assigned a placement in intensive care at a district general hospital. As is the norm, I very much looked up to the male consultant we were attached to, but when I told him it was my dream even back then to do intensive care medicine as a career, he told me it was not a career for females. When I left the hospital that evening, my world fell apart. Dramatic as it sounds, I was honestly devastated. It was like I had been hit with a wrecking ball; all this time I had no idea I was inherently inadequate and what was I supposed to do with my dreams now?

Thankfully this was just a temporary break in my self esteem. I soon remembered who I was and where I came from and I have never encountered a similar attitude from any of my intensive care mentors since. In fact my experience since has been very much the opposite and I have some consultants at University Hospital Coventry and Warwickshire to thank for that.

Yesterday The Department of Health Published it’s own equality impact assessment (EIA) on the junior doctor contract they have lined up for imposition and we were reminded that the facade of support for gender equality in the workplace is depressingly fragile. As a female I read the words with absolute disbelief and perhaps simultaneously the most comforting and frustrating thing is that every single male doctor I have spoken to has shared the same reaction.

“We consider that any indirect adverse effect on women is a proportionate means of achieving a legitimate aim”

“…could give rise to inequalities implications…..but if this were the case we consider that any impact would be justifiably legally as indirect impact resulting from a legitimate aim”

“…while this may disadvantage lone parents (who are disproportionally female)….in some cases this may actually benefit other women, for example where women have partners…”

I will not linger on the point that the ‘legitimacy’ of aims are only as trustworthy as those in charge and that so far, The Department of Health have not at any stage proved that their association of the new junior doctor contract with a so called ‘seven day NHS plan’ is remotely justified. Their aims are far from legitimate and if you take one piece of truth from this writing I would like it to be this, that junior doctors have never been a barrier to improvements in NHS services.

The language used by the department of health in their EIA is both frightening and deeply concerning. But this time, I have absolutely no intention of letting my world fall apart, temporarily or otherwise.

The question of course is where do we go now? This is not something I know the answer to, but I know this much; we will not go backwards. We will not accept a contract that attempts to once again kindle the discrimination of female doctors in the medical workforce.

So let me be clear Mr Hunt, I am a female doctor, I am an asset to our NHS and I will not be collateral damage in your plans.